Tarry Stool Research Articles

A rare cause of gastrointestinal bleeding: Duodenal arteriovenous malformation

AbstractArteriovenous malformations are a rare cause of gastrointestinal bleeding. Endoscopic examination can result in a variety of findings, and diagnosis and therapeutic management are uniquely challenging. We present an 83‐year‐old man with a history of hypertension and a 1‐month history of intermittent tarry stools. Esophagogastroduodenoscopy revealed one bulging mass with pulsation in the second portion of the duodenum which was confirmed as a duodenal arteriovenous malformation by angiography. The mass was initially embolized successfully, but subsequent surgical intervention was necessary due to recurrent bleeding eight months after the embolization. A relevant review of English medical literature was also performed in the text.

Recent Anti-platelet Therapy Revealing Underlying Undiagnosed Gastrointestinal Stromal Tumor in Otherwise Healthy Patient

Gastrointestinal stromal tumors (GIST) are uncommon tumors of the gastrointestinal (GI) tract that arise from primitive mesenchymal cells. Usually, GIST presents as chronic gastrointestinal symptoms or obscure gastrointestinal bleed. Not many cases have been reported in the literature with acute symptoms in the setting of recent aspirin use. We report a case of 70-year-old male otherwise healthy who presented to the hospital with the complaint of black tarry stool for the past two days after taking one tablet of aspirin once a day for two days. The patient underwent upper endoscopy which showed a moderate size polypoid mass in the gastric fundus. Initially, standard endoscopic biopsy was negative for malignancy, due to high suspicion for GIST, later the patient underwent upper endoscopic ultrasound with fine-needle aspiration which confirmed low-grade GIST.

Dieulafoy lesion in the jejunum: a rare cause of massive gastrointestinal bleeding

ABSTRACT Dieulafoy lesions are tortuous vascular malformations characterized by thick walled submucosal arteries/large caliber arterioles protruding through a small mucosal defect surrounded by normal mucosa. They can occur in the jejunum/ileum and can cause massive, life-threatening GI bleeding. We present an 80-year-old female with three weeks of black tarry stools, progressive dyspnea on exertion and generalized body weakness with no significant findings on Esophagogastroduodenoscopy (EGD). Push enteroscopy revealed a Dieulafoy lesion in the proximal jejunum and an overlying clot, with oozing of blood noted after clot removal. The lesion was treated with Argon plasma coagulation (APC) and a post-APC fleshy protuberance was clipped to secure hemostasis. It is therefore important to keep a high index of suspicion for jejunal/ileal Dieulafoy lesions in patients with massive GI bleeding of unclear etiology on EGD/colonoscopy.

A Comprehensive Review on the Screening Models for the Pharmacological Assessment of Antiulcer Drugs.

Due to inappropriate diet, smoking, alcohol consumption, regular use of drugs like NSAIDs and sedentary lifestyle, one may feel upper abdominal pain which may be the predictor of the gastrointestinal disorder called Peptic Ulcer. When an imbalance occurs between the defensive factor and aggressive factor of the stomach, ulcer formation in the esophageal lining, stomach, or duodenum takes place. This leads to the formation of small sores that cause pain. Another condition that synergizes the abdominal pain is vomiting materials which look like coffee grounds, blood in the stool, black or tarry stools. This pain may increase after lunch or dinner. This problem persists, that often leads to the gastroenterologist's consultation. There are many antiulcer screening models present for the determination of antiulcer activity of the drug molecule. The main objective of this study is to find which model is best for the determination of antiulcer activity. A literature search was conducted on the databases namely Science direct and PubMed with the help of different keywords such as "Anti-ulcer", "In-vitro models" and "In-vivo models". The search was customized by applying the appropriate filters so as to get the most relevant articles to meet the objective of this review article. There are different research and review papers based on the antiulcer screening models for the determination of antiulcer activity of new drug molecules. On the basis of our study, we found some useful models for the antiulcer activity of drugs and suggested that, if we use in-vitro and in-vivo methods together, then we may obtain the most relevant result in our research area.

A rare case of Goodpasture syndrome concomitant with bleeding jejunal Dieulafoy's lesion.

An 81-year-old man was diagnosed with Goodpasture syndrome (GS) because he met the criteria of positive anti-GBM antibodies, rapid progressive glomerulonephritis and pulmonary hemorrhage. After starting plasmapheresis and steroid pulse therapy, he experienced tarry stool and contrast-enhanced CT revealed an aneurysmal finding in the jejunum. Paroral enteroscopy showed a jejunal Dieulafoy's lesion (DL) with gush-out hemorrhage. Hemostasis was successfully achieved by hemoclipping, and he then experienced no re-bleeding events. GS can present as a jejunal DL, and contrast-enhanced CT is useful for investigating the etiology and site of small intestinal bleeding, which can lead to smooth, effective endoscopic hemostasis.

Adding trans-abdominal elastography to the diagnostic tool for an ileal gastrointestinal stromal tumor: a case report

BackgroundDiagnosis of gastrointestinal stromal tumors (GISTs) in the distal small intestine is difficult by endoscopic ultrasound. This is the first reported case of an ileal GIST, which is diagnosed by transabdominal sonography and strain elastography.Case presentationA 75 y/o woman presented with tarry stool and dizziness. No definite bleeder could be identified by esophagogastroduodenoscopy and colonoscopy. The transabdominal sonography revealed a large heterogeneous tumor involving the muscular layer of the ileum. Strain elastography showed the strain ratio was 6.51. Strain histogram was skewed to the blue side, and mean color value was 230.5, signifying a stiff tumor. GIST was highly suspected. The patient underwent laparoscope-assisted tumor excision and the histological examination confirmed a malignant GIST. The patient was discharged without postoperative event.ConclusionTransabdominal strain elastography could play a role to discriminate small bowel GISTs and other submucosal tumors, especially in the location with difficulty in endoscopic ultrasound.

Corticosteroid-induced Kaposi's Sarcoma Revealed by Severe Anemia: A Case Report and Literature Review.

We herein report a case of gastrointestinal (GI) Kaposi's sarcoma (KS) without cutaneous involvement in a 73-year-old man who had received immunosuppressive drugs for granulomatosis with polyangiitis. After one year of prednisolone use, he presented with tarry stool and severe anemia. Endoscopic and pathological examinations revealed bright-reddish protruding lesions with proliferating spindle cells positive for D2-40, CD34, and HHV-8, which are definitively diagnostic of GI-KS. Drug-induced KS without HIV infection or transplantation is extremely rare, and its clinical features remain unknown. Therefore, we conducted a literature review of steroid-induced KS.

2017 An Uncommon Etiology for Gastrointestinal Bleed in Elderly: Blue Rubber Bleb Nevus Syndrome

INTRODUCTION: Blue rubber bleb nevus syndrome (BRBNS) is a rare congenital anomaly characterized by multiple venous malformations that can appear anywhere on the body, but most often involve the skin and gastrointestinal (GI) tract. GI bleeding usually presents in childhood or early adulthood as iron deficiency anemia. We report a case of BRBNS as a rare presentation of GI bleeding in an elderly patient with no prior history of cutaneous or GI tract involvement of the disease. CASE DESCRIPTION/METHODS: 87-year-old man with a past medical history of hypertension, coronary artery disease and atrial fibrillation (on Xarelto) was transferred to our hospital for evaluation of melena. He presented to an outside institution initially with complaints of dizziness and black tarry stools for 5 days prior to admission. He was hypotensive, labs were significant for hemoglobin (Hgb) of 5.5 g/dL and a positive stool occult blood test. Anticoagulation was discontinued. He underwent esophagogastroduodenoscopy (EGD), which showed friable mucosa in the duodenal bulb but no active source of bleeding. He received 8 units of packed red blood cells (PRBC), but his Hgb only improved to 7 g/dL. A repeat EGD was also unrevealing. He then underwent a nuclear scan, which showed a focus of bleed in left hemi-abdomen, but it was unclear if it was from the small or large bowel. On presentation to our hospital, his Hgb was 6.6 g/dL and he continued to have melena, requiring multiple PRBC transfusions. Push endoscopy revealed diffuse discontinuous multiple vascular blebs of the mucosa in the mid jejunum (Figure 1a), one of which was found bleeding (Figure 1b). Successful hemostasis was achieved with cauterization of the bleeding bleb with argon plasma coagulation (APC) (Figure 1c,d) and a hemoclip placement 2 cm distal to the lesion. Post-procedure, his Hgb remained stable above 8 g/dL throughout the hospitalization. DISCUSSION: Although BRBNS lesions can occur anywhere from mouth to anus, the small bowel is the most common site of GI tract involvement. Its presentation can vary from iron deficiency anemia to massive hemorrhage, intestinal torsion, and rupture. Some patients require lifelong iron replacement and repeated blood transfusions. Push endoscopy is the most important diagnostic modality for GI lesions. Treatment depends on the severity of lesions and can range from supportive therapies such as iron supplementation and blood transfusion to more invasive therapies such as mucosal resection, APC, sclerotherapy or bowel resection.

2716 A Rare Case of Gastric Glomus Tumor

INTRODUCTION: Glomus tumors are benign mesenchymal neoplasms found predominantly in the extremities. Involvement of the GI tract is rare (<2%). Stomach is the most common site in GI tract.(1) Clinical presentation is usually nonspecific and diagnosis is made based on pathological study after surgical resection. We describe the case of a 35 year old male presenting with upper GI bleeding found to have glomus tumor during endoscopy. CASE DESCRIPTION/METHODS: A 35 years old male with past medical history of musculoskeletal low back pain, who was on meloxicam for past several weeks presented to the hospital with complaints of black tarry stool and lightheadedness. This was associated with weight loss. On examination, he was hemodynamically stable, was found to have pallor, there was no icterus. He had mild epigastric tenderness. Esophagogastroduodenoscopy (EGD) was done that showed moderate inflammation with edema, erythema, friability and granularity around the gastric body and the gastric antrum. It revealed a large submucosal non-circumferential mass in the gastric body with no bleeding and no stigmata of recent bleeding (Figure 1). Contrast enhanced CT scan was obtained that revealed a 3 cm enhancing soft tissue mass. Endoscopic ultrasound (EUS) showed an intramural lesion in the body of stomach that appeared to originate from within the muscularis propria (layer 4) (Figure 2). Fine-needle aspiration (FNA) was performed that was positive for neoplastic cells. He underwent laparoscopic resection of gastric mass (3 cm × 3 cm). Biopsies showed a basaloid proliferation of cytologically bland cells growing in nodules with focal areas of fibrosis, some tumor cells showed cytoplasmic clearing. Tumor cells were positive for smooth muscle actin, calponin, h-caldesmon, synaptophysin, desmin. Final diagnosis of glomus tumor of the stomach was made. DISCUSSION: Diagnosis of glomus tumor should be considered in a patient with gastric submucosal mass. The diagnosis is usually by pathology and immunohistochemistry (2). Most of the tumors are benign in nature, malignant changes are rare. They need long term follow up to look for recurrence.

2747 A Rare Case of Esophageal Squamous Cell Carcinoma With Intramural Gastric Metastasis

INTRODUCTION: Esophageal cancer makes up about 1% of all cancers diagnosed in the United States . Gastric metastasis from esophageal cancer is relatively rare. Four different types of metastatic mechanisms were reported: 1) via peri-gastric lymph nodes; 2) gastric intramural metastasis; 3) direct invasion of the gastric wall, and 4) intra-epithelial spread to the gastric epithelium . Here we present a case with intramural gastric metastasis in a patient with esophageal squamous cell carcinoma. CASE DESCRIPTION/METHODS: A 76-year-old Indian male with past medical history significant for idiopathic pulmonary fibrosis and coronary artery disease, recently started on aspirin and clopidogrel, presented with new onset fatigue and five days of black tarry stools. Hemoglobin (Hgb) on admission was 7.1 g/dL. Despite transfusion of one unit of packed red blood cells, repeat Hgb dropped to 6.6 g/dL. Emergent upper endoscopy was performed for suspected active gastrointestinal bleeding in the setting of blood thinner use. Endoscopy showed a 3 cm, non-bleeding, fungating and ulcerated mass in the middle third of the esophagus, as well as a 4-5 cm fungating, infiltrative and ulcerated gastric mass in the cardia with stigmata of recent bleeding (adherent clot) (see Figure 1). Removal of the clot revealed underlying oozing from the ulcer bed which was treated successfully with dilute epinephrine injection followed by hemostatic clip placement. Forceps biopsies of both the esophageal and cardia masses were obtained. Histopathology of both lesions revealed keratinized squamous cell carcinoma. CT of the chest, abdomen and pelvis showed no evidence of other metastatic disease. Oncology consultation was scheduled to discuss potential chemotherapy, radiation, and endoscopic interventions. DISCUSSION: Esophageal cancer with intramural gastric metastasis is very rare compared to other mechanisms of tumor spread. The prognosis is very poor with the mean survival time reported to be 8.6 months . Conventional chemotherapy or radiotherapy after surgery were ineffective in improving prognosis in current report, suggesting other techniques could provide a benefit when used adjunctively or in combination with more traditional approaches.

Different phenotypes of gastric fundic gland polyposis and cancer in patients with familial adenomatous polyposis depending on Helicobacter pylori infection

A 37-year-old male with tarry stool presented to our hospital. Esophagogastroduodenoscopy revealed advanced gastric cancer, fundic gland polyposis (FGPsis), and negativity for Helicobacter pylori (HP) infection. Computed tomography exhibited multiple liver tumors. Total colonoscopy (TCS) demonstrated 139 tubular adenomas. He was diagnosed as having unresectable gastric cancer and received systemic chemotherapy. His sister and mother had colorectal adenomatous polyposis as revealed by TCS. His sister had FGPsis and was negative for HP infection, whereas his mother had early gastric cancer with HP infection but not FGPsis. Genetic analysis revealed a novel mutation in exon 15 of the APC gene (NM_000038.5: c.7647_7648_delTG) for the patient, his mother, and his sister, whereas no mutation was found for his father who had no gastrointestinal polyps. Therefore, the pedigree was diagnosed as an FAP family with a novel APC germline mutation which had different gastric phenotypes depending on the status of HP infection.

Bernard Soulier Syndrome: Presenting As High-grade Fever In A Young Male

Bernard-Soulier syndrome (BSS) is a rare inherited disorder of blood clotting (coagulation). They may be life-threatening and demand immediate attention. Congenital bleeding disorders especially pose a diagnostic challenge to the clinician because of their rarity and the need to be differentiated from the other common causes of bleeding in children. We present a case of young male presenting with generalized weakness, high grade fever with chills, dry cough and black tarry stools (2-3 stools/day). No response to steroids and further evaluation by platelet, ADP, collegen, epinephrine and defective response to ristocetin led to the correct diagnosis – Bernard soulier syndrome (BSS). However, it is imperative to have arrived at correct diagnosis in order to save unnecessary therapy and to take due precautions for prevention of bleeding

Colonic intussusception as a rare manifestation of colonic lipoma: Case report

Introduction: Colonic lipomas are low-risk lesions that require endoscopic or surgical management depending on their size and symptoms. However, diagnosing a lipoma­tous lesion in the colon is a difficult task, as the clinical or imaging findings point to a low prevalence of these lesions and a higher fre­quency in the female sex. The laparoscopic approach is the current method of choice as it represents fewer traumas and, therefore, a faster clinical recovery.Case presentation: 43-year-old female patient, Caucasian, from the city of Bogotá, housewife, without any medical history. She presented with acute abdominal pain associated with tarry stools. Diagnostic imaging tests were performed, finding colo-colonic intussusception, originated in a lipomatous lesion located in the transverse colon. This patient underwent an enlarged lap­aroscopic right hemicolectomy.Discussion: This case describes how colonic intussusception constitutes a preoperative complication that requires surgical management since its diagnosis considering the associated mortality rates.Conclusion: The analysis of this case is part of the scientific evidence indispensable to im­prove the diagnostic and therapeutic approach to colonic intussusception, as local and in­ternational literature have not addressed this condition sufficiently.

Giant Brunner’s Gland Adenoma Presenting as Upper Gastrointestinal Bleeding in 76 Years Old Male: A Case Report

Brunner's gland adenoma is a rare benign tumor of small bowel, often incidentally discovered during endoscopy or radiological imaging. Mostly they are asymptomatic or often present with nonspecific symptoms such as nausea, vomiting, gastrointestinal hemorrhage, iron deficiency anemia. We reported a 76 years old male case presented with chief complaints of vomiting and black tarry stool. General physical examination was normal except mild tenderness over epigastrium. Esophagogastroduodenoscopy revealed a pedunculated polypoid tubular structure with blind end distally of length approximately 10-12* 3.5*1.5 cm in the second section of the duodenum with multiple skipped ulcers on the exposed surface of it. Additionally, there were few erosions in the duodenum proximally and multiple superficial ulcerations in the antrum, associated with helicobacter pylori confirmed by rapid urease test kit. Surgical or endoscopic excision is the treatment of choice. We consider our case is the eldest case among Brunner's gland adenoma case in literature. Keywords: Brunner's gland adenoma; Brunner's gland hamartoma; Brunner's gland hyperplasia; case report.

Lactobacillus Plantarum CQPC05 Isolated from Pickled Vegetables Inhibits Constipation in Mice

This study mainly investigated the influences of Lactobacillus plantarum CQPC05 (CQPC05) isolated from pickled vegetables on mouse constipation caused by activated carbon water. We used 16S rDNA technology to identify the microorganism, and activated carbon to establish a mouse constipation model. After the mice received L. plantarum (109 CFU/mL) by gavage, small intestine tissue sections were collected. The serum indices and small intestine-related mRNA expression were obtained. A strain of L. plantarum was identified, and named CQPC05. The body weight and activated carbon progradation rate in the mice of the CQPC05 treatment groups were significantly higher than those in the control group, and the excretion time of the first tarry stool was earlier than that of the control group. The results of serum indices indicated that serum gastrin (Gas), endothelin (ET), and acetylcholinesterase (AchE) levels in the CQPC05 treatment groups were significantly higher than those in the control group, while the somatostatin (SS) level was significantly lower. Compared to the constipation control group, the result of q-PCR demonstrated that CQPC05 could up-regulate the mRNA expression of c-Kit (stem cell factor receptor), SCF (stem cell factor), and GDNF (glial cell-derived neurotrophic factor) genes, and down-regulate the expression of TRPV1 (transient receptor potential cation channel subfamily V member 1) and iNOS (inducible nitric oxide synthase). In conclusion, L. plantarum CQPC05 can effectively alleviate constipation, and has good probiotic potential and application value.

Detection of intussusception by point-of-care ultrasound at emergency department: a case report

Case Report A 80-year-old man, with hypertension, hyperlipidemia, and secondary parkinsonism, presented to our ED due to intermittent periumbilical pain for hours. Initial vital signs were stable except high blood pressure (T:36.3’C P:62 beats/min R:18 breaths/min BP:178/91mmHg). Physical examination showed right side abdominal tenderness and positive peritoneal sign. He denied fever, dyspnea, nausea/vomiting, diarrhea, tarry or bloody stool passage, nor trauma history. Point-of-care Ultrasound (POC-US) was performed by ED physician revealing the target sign (Figure 1) and the pseudokidney sign (Figure 2) over right side abdomen without obvious fluid accumulation in the peritoneum. Abdominal computerized tomography (CT) with contrast enhancement was further done reporting highly suspecting ileocolic intussusception (Figure 3). Emergent laparotomy revealed ileocecal intussusception with one polypoid tumor on terminal ileum which might be the leading point. Right hemicolectomy with LN dissection and ileo-transverse anastomosis were done. He was discharged days later and had follow-up at Outpatient Department. Discussion Intussusception refers to a process in which a segment of intestine invaginates into the adjoining intestinal lumen.In adults, intussusception accounts only for less than 5 percent of mechanical bowel obstructions.12Typically, it's owing to pathologic lead point within the bowel, which is 50 percent due to malignancy. 34Among adults, intermittent abdominal pain may be the most common presentation. Due to low incidence rate and unspecified presentation among adults, the diagnosis isn't often made until abdominal computerized tomography (CT) was done. In this situation, point-of-care ultrasound (POC-US) can be helpful to have early diagnosis of intussusception and early intervention in order to avoid necrosis or perforation of intestines. In our patient, intermittent periumbilical pain was the initial presentation. POC-US was performed by ED physician and under impression of intussusception, further abdominal CT and GS consultation were arranged right away. Early diagnosis and early intervention may avoid further necrosis or perforation of intestines. By using POC-US, ED physicians could rapidly detect specified lesions by real-time images and could detect the dynamic changes. And, most important, POC-US is a non-invasive and radiation-free tool that may be used as the primary tool to screen acute abdominal emergencies.

A Pseudo to Pseudo Connection: Pseudoaneurysm Draining Into the Pseudocyst

Pseudohemobilia or Hemosuccus Pancreaticus (HP) is a rare cause of gastrointestinal (GI) bleeding from an aneurysm of peripancreatic vessels that ruptures into a pancreatic pseudocyst, and blood travels through the pancreatic duct as a conduit entering the GI tract through the ampulla of Vater. We are highlighting a case of a 65-year-old female with past medical history of chronic pancreatitis who presented with multiple episodes of dark tarry stools for one day. Her vitals were stable and systemic examination was unremarkable. Laboratory evaluation was only significant for a hemoglobin of 6.7mg/dl and Doppler ultrasound of the abdomen revealed a 8.3 cm ovoid echogenic structure in the midline near the superior mesenteric artery with bidirectional flow suggesting a pseudoaneurysm raising suspicion for communication with pseudocysts. Contrast-enhanced CT showed multiple pancreatic pseudocysts connecting with a large 7.9 x 7.5 cm pseudoaneurysm close to the pancreatic head. (Figure 1) Emergent angiography was done revealing a large pseudoaneurysm arising from the middle part of the gastroduodenal artery with contrast extravasation into pseudocyst depicting active hemorrhage. (Figure 2) The pseudoaneurysm was embolized by microvascular plug (MVP) devices. Post-embolization angiogram showed preservation of hepatic arterial supply and patent portal vein with good flow towards the liver. (Figure 3) Sandblom first coined the name “hemosuccus pancreatitis” in 1970. (1) It's a rare and potentially lethal cause of GI bleed found mostly in men. (2) Most common cause of HP is the chronic recurrent pancreatitis resulting in pancreatic pseudocysts formation. (3) Pseudocyst induced pressure necrosis and autodigestion by pancreatic enzymes from repeated episodes of pancreatitis weaken the surrounding vessel walls and result in the formation of the pseudoaneurysms. (3) Rupture of these pseudoaneurysms into pseudocysts or sometimes directly into the pancreatic duct heralds GI bleed. This poses a diagnostic and management challenge due to the novelty of the condition and difficulty of diagnosing it with endoscopy because of the intermittent nature of the bleeding. Angiography is considered to be the gold standard as it not only serves a diagnostic role but also as a therapeutic modality. (4) Physicians should keep a high index of suspicion for HP in high-risk patients with a normal endoscopy.1359.tif Figure 1: Contrast-enhanced CT scan of the abdomen reveals a 7.9 x 7.5 cm mass adjacent to the pancreatic head. High-density area(arrow) corresponds to active hemorrhage in the pseudoaneurysm.

Rapidly Developing Mixed Acinar-Neuroendocrine Carcinoma of the Stomach

We present a case of a rare, rapidly developing mixed acinar-neuroendocrine carcinoma of the stomach that presented with acute melena and symptomatic iron-deficiency anemia in a patient with history of hepatitis C cirrhosis and lymphoma. A 71-year-old man with history of stage IIIA diffuse large B-cell lymphoma (treated 17 years ago), chronic hepatitis C and compensated cirrhosis (SVR achieved after completing Harvoni therapy 2 years ago) who presented with subacute dyspnea and weakness which began one week after experiencing 8 days of tarry stools associated with epigastric pain. Labs revealed new iron-deficiency anemia with Hgb 8.0 g/dL (previously 12.7) and ferritin of 6 ng/mL. Diagnostic EGD revealed a 3cm clean-based ulcer in the lesser curvature of the gastric body (Image 1 and 2). Notably, 14 months prior to this presentation, an EGD for varices surveillance did not reveal any gastric pathology. Histology of the ulcer edge revealed poorly differentiated neuroendocrine carcinoma, favoring small cell type. Patient underwent distal subtotal gastrectomy with D2 lymphadenectomy and Roux-en-Y reconstruction. Surgical pathology confirmed the diagnosis of poorly-differentiated mixed acinar-neuroendocrine carcinoma (T3N1M0). Immunohistochemistry stained positive for: chromogranin (diffuse); synaptophysin (+ patchy); chymotrypsin (patchy). Ki-67 proliferation index was 70%. Mixed acinar-neuroendocrine carcinomas are rare gastrointestinal tract tumors that typically originate from the pancreas. To our knowledge, this subtype of tumor has been described originating from the stomach in only 5 previous instances. Histologically, both acinar and endocrine components constitute a significant proportion (>25%) of the neoplasm. The progression of this neoplasm was quite rapid as there was no evidence of gastric pathology 14 months prior to diagnosis. Our patient underwent successful gastrectomy and completed 2 [of 4 planned] cycles of platinum-based chemotherapy. He has had no evidence of disease recurrence as of 11 months post-operatively.2671_A Figure 1 No Caption available.2671_B Figure 2 No Caption available.

Aortoenteric Fistula with Duodenal Graft Material Migration Resulting in Gastrointestinal Bleeding

Introduction: Aortoenteric fistula (AEF) is an abnormal connection between the aorta and the gastrointestinal tract. AEF is a rare but life-threatening condition that requires emergent intervention. It usually results from a compression of an abdominal aortic aneurysm (AAA) or after an aortic surgery. Case summary: A 78-year-old male with a history of abdominal aortic dissection status post repair and mechanical aortic valve on chronic warfarin, presented to the emergency department (ED) with upper abdominal and lower back pain, black tarry stool and one episode of hematochezia. While in the ED, he had an episode of hematemesis and was noted to be hypotensive, so he was admitted to the intensive care unit. A Computed tomography (CT) scan of the abdomen and pelvis with contrast showed a calcified aortic plaque with surrounding soft tissue thickening and abutting of the second part of the duodenum, concerning of abdominal aortic dissection without contrast leak (Figure 1). Gastroenterology team performed an emergent Esophagogastroduodenoscopy (EGD), which showed blood in the fundus and an ulcer like lesion in the third portion of the duodenum with a graft material concerning for aorto-enteric fistula (Figure 2). Vascular surgery took the patient emergently to the operating room and performed an endovascular abdominal aortic aneurysm repair to control the acute bleeding. The plan was to do a definitive repair of the aorta and the aortoenteric fistula once he is more stable. Two days later the patient underwent removal of the aortic graft, duodenal diverticulectomy and duodenotomy repair, and replacement of abdominal aortic graft with HEMASHIELD?graft. The graft was found to be infected, so infectious disease team recommended discharging him home on intravenous IV antibiotics for 6 weeks. On follow up the patient was recovering well without any further GI bleeding. Discussion: Aortoenteric fistulae are uncommon but associated with high mortality. It should be considered in the differential diagnosis of upper gastrointestinal bleeding, especially in patients who have an aortic aneurysm or had a repair of an aortic disease.2996_A Figure 1. A: CT scan of the abdomen and pelvis showing calcified aortic plaques, B: CT scan of the abdomen and pelvis showing aotoenteric fistula.2996_B Figure 2. A: An EGD showing blood in the fundus, B: EGD showing an ulcer in the third part of the duodenum with graft material.

Hepatocelluar Carcinoma Invading the Gallbladder - A Rare Cause of Hemobilia

Bleeding from the hepatobiliary tract (hemobilia) is a rare cause of acute upper GI bleed. It should be considered in any patient with recent history of hepatic parenchymal or biliary intervention, angioembolization, blunt abdominal trauma or hepatic malignancy. We describe a rare case of hemobilia due to hepatocellular carcinoma (HCC) invading the gall bladder wall. A 52- year old female with Laennec's cirrhosis complicated by HCC status post transarterial chemoembolization (TACE) presented with black tarry stools, dizziness and abdominal pain. Physical examination was significant for right upper quadrant tenderness to palpation and melanotic stools. Labs were consistent with severe anemia, thrombocytopenia and liver profile derangement. An MRI performed the month prior to admission, demonstrated a 3.1 cm oval-shaped, arterial phase enhancing lesion in the lateral aspect of the right hepatic lobe, suspicious for residual HCC (Fig A). She was aggressively transfused multiple blood products, placed on a proton pump inhibitor and started on octreotide. An emergent EGD was performed which identified blood oozing from the ampulla of vater; consistent with a diagnosis of hemobilia (Fig B). A CTA was negative for active extravasation. The presumed etiology was invasion of the residual HCC into the gall bladder wall given the close proximity identified on MRI. Given her history of TACE and severe liver dysfunction, she was not a candidate for embolization and she was medically managed. First recorded in 1654 by Francis Glisson, hemobilia is an exceedingly rare condition with unknown exact incidence. Traumatic etiology accounts for 40-80 percent of all cases. In patients with HCC, invasion into the blood vessels is a frequent feature, however gallbladder and ductal invasion is widely unrecognized. One study involving 24 patients with HCC was performed to describe the features of intra-biliary duct invasion. 21 percent developed hemobilia; one patient subsequently died from hemorrhagic shock. Approximately one-third of all patients will present with quinke's Triad: acute upper GI bleed (100 percent), biliary colic (70 percent) and jaundice (60 percent). Diagnosis is by visualizing blood from the Ampulla of vater via EGD or ERCP. The best diagnostic and therapeutic intervention is angiography with embolization (success rate > 95 percent). Despite aggressive intervention, severe hemobilia has been shown to have a mortality as high as 25 percent.1950_A Figure 1. A 3.1 cm oval shaped arterial phase enhancing lesion in the lateral aspect of the right hepatic lobe (arrow) suspicious for residual HCC within close proximity of the gall bladder.1950_B Figure 2. EGD oozing from the ampulla of vater (A) and showing blood oozing within the second part of the duodenum (B).